Anxiety Disorders: Living on a Thin Line

FROM an early age, Grace Mahoney's life was ruled by fear. She recalls having her first panic attack in nursery school, and "it kind of progressed from there," said Ms. Mahoney, 38, of Jackson Hole, Wyo. The attacks would strike randomly, even waking her up.

She became so frightened of having an attack that she avoided situations where she didn't have control. "We would visit my uncle in New York who lived on the 39th floor and my father would walk up all 39 flights with me because I wouldn't get in the elevator," she said.

Ms. Mahoney never told anyone about her distress. "Adults would say, 'Oh, she's just shy,"' she said. "But I was scared and depressed." Finally, at age 18, she was diagnosed with panic disorder, a serious anxiety condition.

According to the National Institute of Mental Health, anxiety disorders affect 19.1 million people in the United States, and women have twice the risk as men. Their effects can be devastating. "These disorders cause as much interference in functioning as the most severe chronic physical disorders like pulmonary disease or cardiovascular problems," said David H. Barlow, the director of the Center for Anxiety and Related Disorders at Boston University.

Studies show that these disorders account for billions a year in medical costs. Symptoms can mimic illnesses like heart attacks, and sufferers are three to five times more likely to see doctors and six times more likely to be hospitalized.

Anxiety disorders include panic disorder, which are episodes of intense fear; phobias, which are irrational fears of a place or thing; generalized anxiety disorder, which is chronic worrying; post-traumatic stress disorder, linked to a traumatic event; and obsessive-compulsive disorder, which involves repetitive behavior or disturbing thoughts.

Many disorders overlap. For instance, the fear of having a panic attack can lead to phobias. During a panic attack -- a type of fight-or-flight response, a mechanism that protects us from danger -- the autonomic nervous system activates the adrenal glands to produce adrenaline and noradrenaline. Blood rushes to the large muscle groups, the heart beats rapidly, breathing accelerates -- giving the person greater abilities to run from or fight a predator. But when there's nothing to be afraid of, the response itself becomes scary.

Why are women more at risk for these disorders? While no one knows all the reasons, experts say that genes and environment play a large role. "We have genes that predispose us to anxiety," Dr. Barlow said. "Yet many people have these genes and never suffer any untoward consequences. There has to be interaction with learning and environment, so the environment turns on the genes."

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Early learning experiences set off these genes, he said. "Despite the advances we've made, most girls are not socialized to experience as much mastery and control as boys are."

What about hormones? "They don't seem to play into the genesis of these disorders as far as we know," Dr. Barlow said.

But hormonal fluctuations may exacerbate anxious symptoms, said Dr. Catherine Birndorf, director of the Payne Whitney Women's Program at NewYork-Presbyterian Hospital. "It's the up and down in the menstrual cycle that can lead to disregulation of brain chemistry, which may increase vulnerability."

Disorders tend to show up during adolescence and up to mid-30's. A stressful event is often a catalyst. "It's usually within six months to a year after someone has gone through some major stress," said Jerilyn Ross, president of the Anxiety Disorders Association of America and a psychotherapist who treated Ms. Mahoney. "They get through it fine and then seemingly out of the blue they have a panic attack or they start worrying obsessively."

The encouraging news is that most anxiety disorders are treatable with therapy or medication, or both. The first line of defense is cognitive behavioral therapy, which focuses on changing distorted thinking and confronting painful situations. Medications like selective serotonin reuptake inhibitors and older tricyclics are commonly prescribed. Benzodiazepines are sometimes used shortterm but they can be habit forming.

In future, anti-anxiety medication will become much more focused, which may reduce side effects, said Dr. Michael Liebowitz, director of the Anxiety Disorders Clinic at the New York State Psychiatric Institute. "The search is on for more discrete drugs that will only hit certain receptors" in the brain, he said. "People are working on the dopamine system, seratonin system, the GABA system and other targets."

The crucial step is to get help. Anxiety disorders will make your world smaller and smaller, Ms. Ross said. "You start turning down a promotion because you're afraid to fly, or you start taking roundabout ways to avoid going over a bridge, and then you start avoiding all bridges. Left untreated, these disorders will seep into all areas of your life."